Surgically implanted prostheses guidelines

The provision of surgically implanted prostheses

These guidelines are in line with the Workplace Injury Rehabilitation and Compensation Act 2013 (WIRC Act) and the Accident Compensation Act 1985.

WorkSafe will have regard to these guidelines when making decisions for the provision of surgery which requires the implantation of a prosthesis or medical device to people who have an accepted claim under the Victorian Workers Compensation Scheme.

Throughout these guidelines, any reference to WorkSafe also includes WorkSafe’s agents and self-insurers.

Surgically implanted prostheses

WorkSafe can fund surgically implanted prostheses to assist people to effectively recover from workplace injuries and safely return to work and normal life.

A surgically implanted prosthesis is a piece of equipment or device that is placed into the body during a surgical procedure to replace or assist the body function. WorkSafe refers to the ‘Prescribed list of medical devices and human tissue products’ (the Prescribed List) published by the Department of Health and Aged Care, to determine which prostheses are clinically effective and the reasonable cost of the prostheses.

Examples of products on the Prescribed List include:

• hip, knee or shoulder joint replacement devices
• vascular and cardiac stents
• human tissue items, like bone or bone fragments, vascular grafts, corneas and heart valves.

The Prescribed List has more than 9,000 surgically implanted prostheses.

The Department of Health and Aged Care and an advisory committee of medical practitioners and other health specialists known as the Medical Devices and Human Tissue Advisory Committee (MDHTAC) evaluate the clinical effectiveness and cost effectiveness of prostheses for inclusion on the Prescribed List.

What we can pay for

WorkSafe can pay the reasonable costs of surgically implanted prostheses a person needs as a result of a work-related injury or illness under Victorian workers compensation legislation.

The treatment or service must meet the following criteria.

• Be clinically justified, safe and effective.
• Be likely to achieve measurable improvement in a person’s functioning.
• Promote progress toward a person’s functional independence, participation and self-management.
• Be for rehabilitation purposes for a work-related injury only.
• Be delivered in line with the Clinical framework.

WorkSafe can pay for the following treatments and services.

• Prostheses currently included on the Prescribed List and invoiced in accordance with the Prescribed List and WorkSafe's guidelines.
• Treatment performed in accordance with the applicable MBS items, explanations, definitions, rules and conditions, unless otherwise specified by the agent.
• Consumables listed on the Prescribed List. All other consumables are considered payable under the hospital bed fee and or theatre band fee as detailed in the private hospital services policy.

WorkSafe will periodically review a person’s entitlement to make sure treatment and services remain reasonable, clinically justified, outcome focused and payable under the legislation.

Services we will not pay for

Under the Victorian workers compensation legislation, WorkSafe cannot pay for the following surgically implanted prostheses services.

• Services that are not required as a result of a worker’s accepted injury or illness.
• Services for a person other than the person with an accepted claim.
• Services that are not a reasonable cost as determined in accordance with the Victorian workers compensation legislation.
• Services provided outside of Australia without prior approval from WorkSafe.
• Services provided by a person who cannot practice in the relevant profession under the Health Practitioner Regulation National Law because they are either:
  • not registered
  • registered as a student, or
  • hold non-practising registration.

Worksafe will not pay for surgically implanted prostheses services without prior approval from WorkSafe.

Under WorkSafe’s determination of reasonable cost, WorkSafe will not pay for the following costs relating to surgically implanted prostheses.

• Where the prosthesis and associated surgical procedure has not been approved by the agent.
• Treatment required for a condition that existed before the work-related injury or illness or that is not a result of the work-related injury or illness.
• Where the required documentation has not been provided to the agent.
• Items not currently included on the Prescribed List unless the request meets the criteria required in WorkSafe’s non-established, new or emerging treatments and services (NeNETs) policy.
• Australian Register of Therapeutic Goods (ARTG) cancelled items.

Emergency situations

Non-listed prostheses may be used at a medical practitioner's discretion in emergency situations.

Where non-listed prostheses are used, clinical justification may be required by WorkSafe as soon as possible after hospital admission to consider payment for the reasonable costs of that item.

How much we can pay

The benefit listed on the Prescribed List is the only fee payable and there must be an associated item on the MBS that applies to the surgical procedure required to implant that prosthesis.

Sometimes there is a difference between what a provider charges and what WorkSafe will pay as the reasonable cost. If the provider charges more than what WorkSafe will pay, workers will need to pay the difference. In this instance, WorkSafe recommend the provider advise the worker prior to providing any services.

Invoicing Requirements

For standard invoice requirements, refer to the Instructions for invoicing WorkSafe guidelines.

Invoices must also include the following documentation in relation to the prosthesis.

• A prosthesis item code, description and cost including whether the item is listed on the Prosthesis List.
• From 1 July 2020, any hospital invoices that include prosthesis from the Sub Category: 04.05 - Neurostimulation Therapies for Pain Management on the Prescribed List need to include a copy of theatre records and prosthesis sticker to support the prosthesis invoiced.

In addition to these requirements, ensure that invoices for a surgically implanted prosthesis also include all documentation in accordance with the following policies.

Who can provide these services

WorkSafe will fund only surgically implanted prostheses delivered by medical practitioners that hold the requisite insurance coverage to deliver such services.

Find out how to register as a provider.

Service delivery expectations

WorkSafe expects that all providers delivering surgically implanted prostheses as part of the Victorian workers compensation scheme follow the below principles.

• Provide culturally safe and respectful services.
  • Protect the person’s human rights and report any concerns of abuse, neglect or discrimination to an appropriate regulatory or complaints body.
  • Support the person to maximise their independence, promote recovery and self-advocacy.

WorkSafe also expects that any treatment provided is reasonable, clinically justified, outcome focused, and in line with the Clinical Framework.

WorkSafe has reporting and engagement expectations for all providers delivering services to workers. WorkSafe expects providers to communicate, collaborate and provide information to WorkSafe and other relevant parties as required.

For example:

• Providers should work with treating health practitioners or other providers, such as medical practitioners to enable the most appropriate treatment.
• Providers should work with occupational rehabilitation providers, treating health practitioners and employers in relation to return to work.

Providers are required to comply with the requirements set out in these guidelines and in the Application for registration to provide services to workers.

If a provider does not meet these requirements or WorkSafe has concerns about the provider’s conduct or services delivered, WorkSafe may take appropriate action in accordance with the legislation.